Capital Credits

# A B C D E F G H I J K L M N O P Q R S T U V W Y Z

BULLOCH TELEPHONE COOPERATIVE CLAIM FORM

Existing Member Name(Required)

First Last

Existing Street Address

Street Address Address Line 2 City State ZIP Code

Updated Name(Required)

First Last

Updated Street Address(Required)

Street Address Address Line 2 City State ZIP Code

Account Number

Member Number

Phone Number

In conjunction with the retirement of capital credits prior to 1990, I hereby make the following certification regarding my status or my entities status prior to receiving our patronage refund:

I am a residential customer and have not deducted the cost of communication service on any tax return for the years prior to 1990.

The qualified Member above is deceased and I am claiming the Patronage refund on their behalf. I have included a death certificate and a court document to verify that I am qualified to receive the refund and will distribute the proceeds according to the laws of Georgia.

My entity is incorporated under the corporate laws of Georgia and our state issued control number below.

Control Number

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